On the basis of the present series of studies, the following conclusions can be made:
1. An anterior trapezoid compression external fixator is not optimal for stabilizing a vertically un-stable pelvis (type C injury), and there is a high likelihood of hemipelvis migration. Similarly, an external frame alone cannot reliably stabilize a rotationally unstable pelvis with disruption and wid-ening of the symphysis pubis (type B open book injury).
2. An internally rotated hemipelvis with displaced pubic rami fractures (type B lateral compression injury) is relatively stable, and this injury can be stabilized adequately with an anterior external frame, when indicated, but compression should be avoided during a closed reduction and applica-tion of the fixator.
3. The most severe pelvic arterial bleeding is related to the trunk of the internal iliac artery or its main branches due to a high-energy type C pelvic ring fracture. The worst prognosis is related to exsanguinating bleeding from the main trunk of the internal or external iliac arteries (large pelvic arteries) or from multiple branches of the internal or external iliac systems (high vessel size score).
4. TAE is a reliable method for controlling arterial source of pelvic bleeding with a low rate of complications. In massive hemorrhage with several bleeding arteries uni- or bilaterally, it is reason-able to use non-selective embolization by promptly occluding the main trunk of the internal iliac artery, either uni- or bilaterally.
5. In critical situations, a damage control protocol may include temporary extraperitoneal pelvic packing or resuscitative endovascular baloon occlusion of the aorta to achieve early hemorrhage control and provide time for a more selective embolization approach to the bleeding. A multidisci-plinary approach provides the best chance of survival.
6. Type C pelvic ring injuries require surgical stabilization. Internal fixation of all injuries in the anterior and posterior pelvic ring provides superior stability for the whole pelvis and better anatom-ical results as determined by the quality of reduction and lower malunion rate.
7. In type C injuries, an anatomical or near-anatomical reduction (displacement ≤ 5 mm) is more often associated with a good functional outcome and therefore that should be the goal of operative treatment. However, the prognosis is also often dependent on associated injuries, particularly a permanent lumbosacral plexus injury. Conversely, it is unusual to obtain a satisfactory functional
result in the presence of a fair or poor fracture reduction.
83
8. H-shaped sacral fracture with spinopelvic dissociation is a rare injury pattern. Segmental lum-bopelvic fixation is a reliable treatment method for these injuries and it provides sufficient stability for fracture union with a low rate of complications and long-term sequelae.
9. H-shaped sacral fractures with spinopelvic dissociation are associated with neurologic impair-ment in nearly all cases. The Roy-Camille classification of these fractures (1985) is not prognostic of neurological impairment after operative treatment. Neurological recovery and clinical outcome are associated with the degree of initial translational displacement of the transverse sacral fracture.
Permanent neurological deficits are more frequent and the clinical outcome worst in completely displaced transverse sacral fractures.
10. In spinopelvic dissociations, quality of reduction in terms of residual postoperative vertical and AP displacements in the vertical sacral fracture lines and translational displacement and kyphosis in the transverse sacral fracture, is associated with the clinical outcome. Accurate reduction of all sa-cral fracture components is associated with better clinical outcome.
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ACKNOWLEDGEMENTS
This study was carried out at the Department of Orthopaedics and Traumatology, Helsinki Universi-ty Hospital and UniversiUniversi-ty of Helsinki. I want to thank Emeritus Professor Pentti Rokkanen, the Head of the first Department of Surgery, Helsinki University Hospital and the late Professor Seppo Santavirta (†), chief of the Department of Orthopaedics and Traumatology, University of Helsinki for the possibility to work and develop the management concepts of pelvic trauma patients during this project.
I express my sincere gratitude to my supervisor, Docent Eero Hirvensalo, who originally suggested the topic of this study to me. As a supervisor, he provided me with his expert guidance and support-ive attitude. I admire his vast knowledge of orthopaedic trauma care. I am glad to have had the op-portunity to co-operate with him all these years.
My sincere thanks go to Docent Jukka Ristiniemi, University of Oulu, and Docent Petri Virolainen, University of Turku, the referees appointed by the Faculty of Medicine, University of Helsinki, for their guidance, constructive criticism and valuable comments during the final phase of the work. I would also like to thank Professor Ilkka Kiviranta for overseeing the progress of this doctoral thesis.
I am grateful to my co-author, Docent Lauri Handolin, for his encouraging support and help with the second paper of this study. His expertise in the acute treatment of high-energy blunt trauma pa-tients, and positive criticism has been invaluable. It has been a pleasure to collaborate with him and all the colleagues and nurses at the emergency department.
I warmly thank my co-author Tim Söderlund for his assistance and for putting so much time and effort in completing the statistical analyses of the second and the fourth papers. In addition, I am very appreciative of all the good discussions concerning different treatment modalities of major pelvic hemorrhage.
I owe special thanks to my co-author, Docent Tatu Mäkinen, for his valuable help, positive criticism and support with the last paper of this study. His extensive knowledge in clinical research has helped me to complete this work.
I want to thank Matti Porras for his invaluable expertise in angiographic embolizations for pelvic fracture-related arterial bleedings. Matti Porras performed most of these life-saving angiographic procedures during the first decade after starting this approach in 1996 at Töölö Hospital.
I warmly thank my co-author Professor Seppo Koskinen, Division of Medical Imaging and Tech-nology, Karolinska University Hospital Huddinge, Sweden, for his expert advice in planning the data collection and evaluating the radiological results in the last paper.
I thank Docent Ole Böstman for giving me good advices in the beginning of this work. I also thank Docent Jarkko Pajarinen, for statistical analyses of the third paper.
85
I thank all my co-workers from Töölö Hospital, especially the pelvic surgeon Veikko Kiljunen, as well as the whole staff of the Pelvis and lower extremity trauma ward for their expertise in the man-agement of pelvic trauma patients and excellent co-working atmosphere.
My very special thanks are given to Professor Wolfgang Grechenig, Graz University Hospital and Professor Friedrich Anderhuber, Chair of the Institute of Anatomy, Medical University of Graz, Austria for having the opportunity to teach pelvic surgery on their courses with practical exercises on human specimens and to perform anatomical studies with their cadavers during the last decade. I also thank Doctor Axel Gänsslen from Wolfsburg Hospital, Germany, for sharing his vast knowledge on pelvic fracture surgery.
I would like to thank Mia Kalervo and Riitta Multala, for their outstanding ability to acquire all the scientific articles I ever needed. I also thank photographer Jukka Alstela for editing the pictures and radiographs.
I wish to express my gratitude and appreciation to my parents Aino (†) and Allan Lindahl (†) for providing a loving and supportive home in which studying and hard-work were highly encouraged.
I warmly thank my brothers Tom and Ali for their love and support.
Most importantly, I owe my deepest gratitude to my wife Päivi for her continuing love, support and understanding. I wish to thank also my three children, Joonas, Oona, and Erik for their love and for bringing balance and joy to my life. All the sailing trips and offshore sailing competitions with them in the Finnish archipelago have been a great counterbalance to this work. My family has made me able to understand the difference between what is important and what is less important in life.
This work was financially supported by the Research Foundation for Orthopedics and Traumatolo-gy in Finland, and Helsinki University Hospital (EVO-grant).
Espoo, May 2015
Jan Lindahl
86
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